Critical Appraisal of Research

Full
citation
of selected article

Article #1

Article #2

Article #3

Article #4

Mckelvey, L. M., Edge, N. A., Fitzgerald, S., Kraleti, S., & Whiteside-Mansell, L. (2017).

Adverse childhood experiences: Screening and health in children from birth to age 5. Families, Systems, & Health, 35(4), 420-429. doi:10.1037/fsh0000301

Melville, A. (2017).

Adverse Childhood Experiences from Ages 0–2 and Young Adult Health: Implications for Preventive Screening and Early Intervention. Journal of Child & Adolescent Trauma, 10(3), 207-215. doi:10.1007/s40653-017-0161-0

Schofield, T. J., Donnellan, M. B., Merrick, M. T., Ports, K. A., Klevens, J., & Leeb, R. (2018).

Intergenerational Continuity in Adverse Childhood Experiences and Rural Community Environments. American Journal of Public Health, 108(9), 1148-1152. doi:10.2105/ajph.2018.304598

Zare, M., Narayan, M., Lasway, A., Kitsantas, P., Wojtusiak, J., & Oetjen, C.A. (2018).

Influence of adverse childhood experiences on anxiety and depression in children aged 6 to 11 years. Pediatric Nursing, 44(6), 267-274, 287.

Conceptual Framework

Describe the theoretical basis for the study

Childhood toxic stress, precipitated by ACEs, is associated with biological changes in the developing brain and body that affect concurrent and long-term health and behavior.

Exposure to adversity, such as trauma, neglect, and abuse, in childhood has been identified as a major global public health issue. I chose this article because it focused on the assessment of ACEs that occurred in the early development of children. It explored the short and long-term impacts of childhood adversity during specific developmental periods, such as infancy and toddlerhood.

ACEs show intergenerational continuity and their impact on health and well-being can be repeated across generations. I chose this research article because it focused on reducing or preventing ACEs and its potential to produce long-lasting benefits in both the physical/mental health and quality of life across generations. How effective is breaking the chain in a long history of trauma and other childhood adversities?

I chose this last research article because it examined the association of adverse childhood experiences with depression and anxiety in children aged 6 to 11 years old. The article explains that when children experience prolonged stressors such as ACEs, both a chemical and physical change can occur which can alter the neural pathways and the metabolic processes. This can lead to lifelong issues both with mental health and chronic illnesses.

Design/Method
Describe the design

and how the study

was carried out

The survey asked all respondents the same questions in the same order to allow for statistical analysis. The survey gathered a narrow amount of information, 10 yes or no questions, from a large number of respondents. All of the questions were closed questions for quantification in order to be coded and processed quickly.

This study used data collected for the evaluation of voluntary home visiting services funded through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program in the state of Arkansas.

This study examined whether there is evidence to support a screening approach that assesses children’s current exposures to risks that act as precursors for ACEs, measured in a way that falls below a threshold of explicit abuse, neglect, or illegal behavior.

Mixed-methods research- The study examined the relationship between ACEs measured from age 0–2 and adult health outcomes using data from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) dataset which pull data from five national data collection sites. The data included past ACE scores as well as CPS reports and self-proclaimed adverse childhood experiences.

Quantitative research – During each assessment period, professional interviewers made home visits to each family for approximately 2 hours on 2 occasions. At each visit, father, mother, and adolescent independently completed a set of questionnaires in separate rooms covering an array of topics related to work, finances, school, family life, mental and physical health status, and social relationships.

Quantitative research – This article used data already collected by the National Survey of Children’s Health (NSCH).

The NSCH collected interviews randomly all over the US of 95,677 children. This article took those surveys that applied to children aged 6-7 which included 31,060 children. The article focused further on only depression and anxiety relevant answers. Coding the answer as no or yes. Then that data was correlated with ACEs scores received from the same survey.

Sample/Setting

The number and

characteristics of

patients

,

attrition rate, etc.

2,004 participants

Families were eligible for services if they reported at least one of the following risks: low income (250% of federal poverty), homelessness, single and/or teen (aged 19 or younger) parent(s), parent mental illness, substance abuse, incarceration, military deployment, disability, suspected child maltreatment (based on referrals from child-protective services), child developmental delay, preterm/low-birth weight, or chronic illness.

139 participants

Child Maltreatment Physical Abuse 17.4% (24), Emotional Abuse 8% (11), Physical Neglect 8.7% (12), Household Dysfunction Caregiver mental illness 35.5% (49), Substance use 34.8% (48), Caregiver treated violently 40.3% (60), Criminal household member 3.6% (5), Caregiver separation/divorce 11.6% (16).

451 two-parent families via telephone through the cohort of all seventh-grade students (aged 12–13 years) in 8 counties in north central Iowa who were enrolled in public or private schools during winter and spring of 1989. An additional criterion for inclusion in the study was the presence of a sibling within 4 years of age of the focal seventh grader. Seventy-seven percent of the eligible families agreed to participate in the study. We first conducted interviews in 1989 with adolescents (G2) and their parents (G1) when they were in seventh grade.

The NSCH was conducted using telephone numbers that were dialed at random to identify households with children under 18 years old. In total, interviewers contacted 847,881 households, of which 87,422 households had age-eligible children, and interviews were completed on 95,677 children. The sample for the analysis included only children between the ages of 6 and 11 years. This subsample included 31,060 children.

Major Variables Studied

List and define dependent and independent variables

Demographic controls and family resources scale scores. Below poverty line. Primary caregivers were 28 years of age (range = 13–74), White (60%), and had a high school education or less (61%). Children were 32 months of age (range = 13–76 months) and approximately half (51%) were male.

ACEs Measured early childhood ACE categories of child maltreatment were physical abuse, emotional abuse, and physical neglect. Household dysfunction was measured by caregiver mental illness, caregiver treated violently, incarceration, substance abuse, and parental separation or divorce. Traditional ACE categories of sexual abuse and emotional neglect were not measured due to limited variance of available data

ACEs items included indicators of abuse (physical, sexual, emotional), emotional neglect, and other household challenges (parent treated violently by spouse, household substance abuse, household mental illness, and parental separation or divorce). Community characteristics (block group level) Low socioeconomic status 6.42 (3.07), Population density (people per mi2) 227.93 (493.49), Perceived lack of community services (scale 1–4) 3.09 (0.29), Perceived community social cohesion (scale 1–4) 3.00 (0.27), Alcohol vendor density (vendors per km2) 4.13 (7.76)

outcome variable, namely depression and/or anxiety.

Sociodemographic variables included race/ethnicity (Hispanic, White non-Hispanic, Black non-Hispanic, and Other; “Other” includes Asian, Ameri can Indian, Native Alaskan, Native Hawaiian, Other Pacific Islander and multi-racial children), family structure (two biological parents, parent and step-parent, single mother-no father, other family type), sex (male, female), and poverty level (0% to 99% Federal Poverty Level (FPL), 100% to 199% FPL, 200% to 399% FPL, 400% FPL or greater). The variable poverty level was constructed based on household income reported in the NSCH.

Measurement

Identify primary statistics used to answer clinical questions

Using logistic regressions to examine the association between FMI-ACE groups (i.e., children in families with scores of 0, 1, 2, 3, and 4 or more FMI-ACEs) and health outcomes.

Odds ratios reported in previous ACE work were used to inform power estimates for logistic regression.

Logistic regression was used to explore whether overall ACE score at age two as well as individual ACE categories predicted health worry and overall health. Both models utilized control variables of child race/ethnicity, gender, and income.

Almost half of the sample in this study experienced two or more ACEs between the ages of 0 and 2. The central finding of this study was that early childhood ACEs, experienced from age 0–2, predicted health worries in adulthood.

During each assessment period, professional interviewers made home visits to each family for approximately 2 hours on 2 occasions. At each visit, father, mother, and adolescent independently completed a set of questionnaires in separate rooms covering an array of topics related to work, finances, school, family life, mental and physical health status, and social relationships. Assessments occurred when the adolescent was in 7th, 8th, 9th, 10th, and 12th grade, as well as a year later, when the adolescents averaged 18 years of age.

The nine adverse childhood experiences included:

•How often has it been hard to get by on your family’s income, such as having enough money for basics like food or housing?

•Did [child’s name] ever live with a parent or guardian who got divorced or separated after [he/she] was born?

•Did [child’s name] ever live with a parent or guardian who died?

•Did [child’s name] ever live with a parent or guardian who served time in jail or prison after [child’s name] was born?

•Did [child’s name] ever see or hear any parents, guardians, or any other adults in [his/her] home slap, hit, kick, punch, or beat each other up?

•Was [child’s name] ever the victim of violence or witnessed any violence in [his/her] neighborhood?

•Did [child’s name] ever live with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks?

•Did [child’s name] ever live with anyone who had a problem with alcohol or drugs?

•Was [child’s name] ever treated or judged unfairly because of [his/her] race or ethnic group?

Data Analysis

Statistical or

qualitative

findings

Results demonstrated significant associations between FMI-ACE scores and the environmental safety of the children, namely the home- and car-safety index and secondhand smoke exposure in the home. The odds of scoring at risk in home and car safety were nearly five times higher for children in families with the highest FMI-ACEs than for those with a score of 0. Further, the odds of secondhand smoke exposure for children with the highest FMIACE scores of 4 or more were four times higher than children with an FMI-ACE score of 0. Children in families with FMI-ACE scores of 2, 3, and 4 or more had twice the odds of having inadequate preventive care than children with FMI-ACE scores of 0. Children with FMI-ACE scores of 2, 3, and 4 or more had significantly higher odds of having emergency or urgent medical care than those with FMI-ACE scores of 0.

Forty-four percent of children in the study had experienced two or more ACEs by age two. Seventeen percent of children in the study had experienced no ACEs, and 39% of the children had experienced one ACE by age two. When exploring prevalence rates for types of early childhood ACEs in this sample, house hold dysfunction rates were more prevalent than child maltreatment adversities, with exposure to domestic violence (44.2%), caregiver mental illness (36.2%), and substance abuse (24.6%) being the most common types of household dysfunction measured. Physical abuse was the most commonly measured type of child maltreatment ACE category (16.7%).

analyses on the basis of restricted maximum-likelihood estimation, with sandwich estimation of SEs to account for some families sharing the same block group. 19 Residents select into particular neighborhoods by preexisting traits, 20 including personality. 21 As a robustness check, we included parent neuroticism and alcohol problems as covariates because they show spatial autocorrelation, 20, 21 have been linked with ACEs in previous studies, 22 and were significantly related to G2 ACEs in this sample.

Descriptive and bivariate analyses were conducted to examine the distribution of adverse childhood experiences and sociodemographic variables, as well as depression and/or anxiety, across the independent variables. Logistic regression analysis was performed to assess the magnitude and direction of adverse childhood experiences on depression and/or anxiety. Collinearity diagnostics were performed to ensure the adverse childhood experience variables in particular were not associated among themselves and other sociodemographic variables.

Findings and Recommendations

General findings and recommendations of the research

The findings suggest a need for home health and safety interventions for families who have reported even one ACE. Screening more widely for ACEs in these contexts would permit targeting of intervention to those families with greater need. The article also found that receiving inadequate preventive health care and receiving urgent medical treatment were more likely for children with two or more ACEs. Also found that being less healthy (i.e., having a chronic condition or screening at risk for developmental delay) was more likely for young children in families with the highest levels of ACEs.

Findings from this study highlight the potential use for the ACE survey as a frame for prevention of risk in early childhood. Traditionally, ACE scores of 4 or more have been associated with increased risk factors in adulthood, however this study highlights early childhood ACE scores of 2 or more as critical within the early childhood frame. It is important for professionals across disciplines who interact with infants and toddlers to be aware of the short and long-term risks that exposure to childhood adversities cause. The ACE survey is a short, easy to administer questionnaire that is able to be incorporated into interdisciplinary settings that encounter infants, toddlers, and their families, thus results from this study are easy to translate into screening recommendations. Short screenings using the ACE survey can easily be incorporated into pediatric visits and other early childhood settings, and ACE scores of 2 or more may prompt a referral to an early intervention program. These findings also emphasize the importance of exploring the role of early intervention programs in helping to mitigate the impacts of adversities and reduce further adversity exposure through family-based services

Exposure to early adversity is associated with a host of health problems, interferes with successful relationship formation, and reduces productivity and success in the workplace. Exposure to these risk factors (collectively called ACEs) shows continuity across generations among families in this rural sample. However, that cycle may be disrupted in White, rural, lower SES communities when adolescents are living in a community with low alcohol vendor density or in a community that their parents characterize as high in social cohesion. If replicated, these findings suggest that efforts to foster social cohesion and limit the density of alcohol vendors may help families break the cycle of exposure to adverse experiences during childhood and adolescence.

Analysis of adverse childhood experience factors indicated that children whose families “very often” and “sometimes” had difficulty affording basics, such as food or housing, were 3.25 (2.26 to 4.68) and 1.79 (1.32 to 2.43) times more likely, respectively, to have depression and/or anxiety compared to children whose families “never” had difficulties affording basic necessities. Children who had lived with a parent or guardian who died were at higher risk (OR = 1.75, 95% CI = 1.13 to 2.70) for depression and/or anxiety compared to children who never lived with a parent or guardian who died. The likelihood of depression and/or anxiety was also higher among children who experienced or witnessed any violence in their neighborhoods (OR = 2.33, 95% CI = 1.63 to 3.04) or were ever treated or judged unfairly because of race or ethnicity (OR = 1.80, 95% CI = 1.17 to 2.78). Further, children who had lived with anyone with mental illness for more than a couple of weeks were almost 3.0 (2.05 to 3.94) times more likely to have depression and/or anxiety compared to children who never lived in a similar situation.

Appraisal

Describe the general worth of this research to practice. What are the strengths and limitations of study? What are the risks associated with implementation of the suggested practices or processes detailed in the research? What is the feasibility of

use in your practice?

This study expanded the readers understanding of approaches to ACE screening. The FMI-ACE screening showed validity in that the measure makes it possible to detect adverse experiences, allowing time for healthcare providers and services to intercede on the child’s behalf to reduce risk of further negative impacts and outcomes. I believe the methodology used was reliable and the results could be used to further research in this filed.

Although this article points to a correlation between early childhood adversity and negative adult outcomes, the data is limited due to the age of the individual and the reluctance for caregivers to report at that age. Thus, may lack in some validity. The study group was small but it raises questions about the link between these early developmental stages and what is impacted by adversity. Specifically, cortisol levels and inflammation in the body with regards to fighting infections that can lead to chronic illness. Its conclusions are consistent and reliable but more research is needed.

This methodology used showed validity due to the fact that it used similar rural areas with a population of similar backgrounds and had a large study group that was assessed over a long period of time. I believe this study also showed reliability due to its consistent results over multiple community groups.

I found this article very reliable as the assessment tools used produced stable and consistent results. I also found that it had validity as the surveys conducted measured ACEs, depression, and anxiety effectively and proved useful when conducting the proposed aim.

This study has several limitations. Because it is a cross-sectional survey, it is not possible to longitudinally examine the effects adverse childhood experiences have on depression and/or anxiety, or to infer causal relationships between adverse childhood experiences or mental health outcomes. Longitudinal data could enable examination of how one set of adverse childhood experiences may influence other adverse childhood experiences (e.g., divorce earlier in childhood may influence economic hardship) based on their onset and frequency in children’s lives.

General Notes/Comments

This study addressed gaps in the literature by documenting the associations between ACE screening scores, less optimal health environments, health-care use, and developmental outcomes for infants, toddlers, and preschoolers. Findings suggest that our approach to ACE screening can identify children whose health is at risk very early in development. Expanding screening for ACEs into pediatric settings could support direct intervention by linking families to assistance, such as home-visiting services, that can support the development of the child.

Pediatric nurses can provide anticipatory guidance to parents and other caregivers about how to prevent adverse childhood experience exposure by seeking safe physical and emotional environments for their children or by seeking counseling for themselves if they are suffering from mental health or substance abuse problems

Author
and
year
of selected article

Study Design

Theoretical basis for the study

This research article examines the association of adverse childhood experiences with depression and anxiety in children aged 6 to 11 years old. The article explains that when children experience prolonged stressors such as ACEs, both a chemical and physical change can occur which can alter the neural pathways and the metabolic processes. This can lead to lifelong issues both with mental health and chronic illnesses.

Sample/Setting

The number and
characteristics of
patients

2,004 patients

Low-income (100% of federal poverty or less) 84.4%, Homeless 5.3%, Single parent 52.4%, Teen parent 11.0%, Suspected abuse/neglect 1.1%, Parent mental illness 3.9%, Substance abuse 3.5%, Incarcerated parent 1.8%, Parent disability/chronic illness 3.1%, Child developmental delay 7.6%, Child low birth weight 8.5%, Child chronic illness 4.8%

139 participants

Child Maltreatment Physical Abuse 17.4% (24), Emotional Abuse 8% (11), Physical Neglect 8.7% (12), Household Dysfunction Caregiver mental illness 35.5% (49), Substance use 34.8% (48), Caregiver treated violently 40.3% (60), Criminal household member 3.6% (5), Caregiver separation/divorce 11.6% (16).

Evidence Level *

(I, II, or III)

Level 2 Quasi-experimental studies / cohort study

Level 1 Randomized control trial RCT

Outcomes

Children were exposed at rates of 27%, 17%, 11%, and 11% to 1, 2, 3, and 4 or more FMI-ACEs, respectively. Logistic regressions revealed significant associations between FMI-ACE scores and health environments and outcomes for children, including health risks in the home (e.g., safety and secondhand smoke exposure), underuse of preventive health care, and overuse of emergency medical treatment. In terms of development, having four or more FMI-ACEs was associated with the child having a chronic health condition and screening at risk for delay in at least one area of development.

2,004 patients

Low-income (100% of federal poverty or less) 84.4%, Homeless 5.3%, Single parent 52.4%, Teen parent 11.0%, Suspected abuse/neglect 1.1%, Parent mental illness 3.9%, Substance abuse 3.5%, Incarcerated parent 1.8%, Parent disability/chronic illness 3.1%, Child developmental delay 7.6%, Child low birth weight 8.5%, Child chronic illness 4.8%

Outcomes

Forty-four percent of children in the study had experienced two or more ACEs by age two. Seventeen percent of children in the study had experienced no ACEs, and 39% of the children had experienced one ACE by age two. When exploring prevalence rates for types of early childhood ACEs in this sample, household dysfunction rates were more prevalent than child maltreatment adversities, with exposure to domestic violence (44.2%), caregiver mental illness (36.2%), and substance abuse (24.6%) being the most common types of household dysfunction measured. Physical abuse was the most commonly measured type of child maltreatment ACE category (16.7%).

During each assessment period, professional interviewers made home visits to each family for approximately 2 hours on 2 occasions. At each visit, father, mother, and adolescent independently completed a set of questionnaires in separate rooms covering an array of topics related to work, finances, school, family life, mental and physical health status, and social relationships. In these White, rural, lower SES communities, high perceived community social cohesion was associated with a reduction in ACEs across generations. This is consistent with cross-sectional work showing a negative correlation between collective efficacy and child maltreatment and points to the importance of social cohesion for health and well-being among rural populations. In addition, the moderation effect shows that social cohesion reduces intergenerational continuity in ACEs.

Key Findings

Appraisal and Study Quality

Peer Reviewed Article

Level

Wang et al., (2017) Normal saline instillation before suctioning

Level I

Provides a meta-analysis from randomized controlled trials involving normal saline use

Schultz et al., (2018) Normal saline instillation versus no normal saline instillation and lung Recruitment versus no lung recruitment with paediatric Endotracheal Suction

Level II

It entails a randomized experiment in which all the members of group are subjected to a particular treatment with normal saline. All the members of the particular group had results recorded then evaluated

Level V

A critical analysis of the qualitative studies surrounding the use of Normal saline in suctioning

Leddy, R., & Wilkinson, J. M. (2015). Endotracheal suctioning practices of nurses and respiratory therapists: how well do they align with clinical practice guidelines?.

Level VII

Involves a thorough analysis of the opinions of RN’s and respiratory theorists on the overall use of NS and observed effects

Author Year

Sample/setting

Key Findings

Appraisal and study Quality

General Comments

N- 825 patients

studies
Setting-respiratory care hospital

Age-(0-16 years) intubated patients

contain full body of research

Potential missed evidence with restriction to only controlled

trials.
Strengths

A large sample of study hence reliable

Identified the exact impact of NS during

Suctioning of respiratory

patients
Conclusion
Use of NS in tracheostomy is

feasible with no supported benefit in suctioning.

Feasibility

Benefits outweigh potential risks

Eliminating NSI is cost effective and EBP friendly

Very relevant to the study with a large sample setting.

The results effectively answer the clinical question of inquiry.

Provides level one evidence which offers best outcomes for professional practise amendments

Setting six hospitals in Ontario.

Private, public and institutional hospitals

Registered nurses and

respiratory
therapists

Does not contain full body of

evidence

Full of bias because it mainly consists of opinions.

Strengths

Compares, opinions from different professionals

Analyses literature on

Subject

Conclusion- moderately reliable since it is level VII but accurate resource on NS application

Provides expert opinion on the application of NS.

Relevant for analysing impact of NS from nursing professionals.

However, being in the levels VII of evidence, must be supported by other stronger sources.

It also

comprehensively reviews literature thus efficient in boosting the knowledge of clinical experts on about the clinical issue.

Generally ineffective unless supported by other sources

Review of quantitative and qualitative literature.

NS instillation in patients and Harmful effects

Large body of sources

Different EBP scholarly sources.

Weaknesses

Does not provide full body evidence since little or efficacy trial employed

conclusion

NSI is harmful to the health

Feasibility

Moderately applicable

Comprehensively reviews literature thus efficient in boosting the knowledge of clinical experts on about the clinical issue.

Generally ineffective unless supported by other sources

N-337 patients

Study setting- ICU in respiratory care.
Intubated patients.

18 -30years

The pooled mean difference between was oxygen concentration was -1.14%

NSI is a common practise in ICU Respiratory care

Low methodology quality

Missing data
Strengths

Large body of sources identified the pooled mean difference in

the saturation of oxygen

as -1.14
conclusion

NSI is harmful to the health, by reducing Oxygen

Saturation in tracheostomy patients.

Feasibility.

Benefits of the entire study outweigh the potential risks.

Research results are reliable and pooled from large resources.

This is one of the most relevant sources to this study with a large population and sample setting.

Being a level two evidence with favourable outcomes, it helps to solve the clinical question and provides a comprehensive answer to the study question